Ob-Gyn Coding Alert

As a follow-up to our March article on coding for more than one surgeon, this article will assist the growing number of ob/gyn practices using or contemplating the use of nurse practitioners (NP), certified nurse midwives (CNM) or physician assistants (PA) to provide first assists in surgery. First assist is a term describing the person who provides immediate assistance to a surgeon during a case that requires an extra, trained and qualified set of hands. This article will clarify the issues and direct the ob-gyn coder toward tactics that will maximize reimbursement.

Will Carriers Pay for Mid-level Providers
Who Assist in Surgeries?

In the course of researching this article, we discovered that many ob/gyn practices (including physicians, managers, coders and mid-levels) are confused about whether an NP, PA or CNM can be paid for first assists. Many see the mid-level surgical assistant as part of the physicians cost. But Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management, Inc., says, Yes, in many cases a mid-level provider can be paid in addition to the physician. However, certain conditions must be met.

First, the surgical procedure has to be one that allows for a professional assistant. While there is no national listing of CPT codes that allow for assists, Brink says that Medicare carriers in many states have such lists in their manuals. If no such listing is found, your only choice is to check with the payer ahead of time or bill the service and see what happens, according to Brink. Many commercial carries have a list of procedures that they do not believe merit assists.

Secondly, the mid-level providing the assist must meet the credentialing criteria of the state in which they work. According to Karen S. Fennell, RN, MS, senior policy analyst for the American College of Nurse-Midwives, these laws and regulations vary greatly across the states and among the different kinds of mid-levels. However, Fennell says that in most places nurse-midwives are fully credentialed and allowed to practice and code as physicians. The various local professional associations for the different mid-levels can be a good source of information about regulations and reimbursement. You can check with the local chapter of the American College of Midwives in your area.

Beyond meeting regulatory criteria, Brink points out that the mid-level provider must also have privileges to practice at the hospital or surgical center when the surgery is being performed.

Finally, in order to bill for mid-level services, the mid-level professional must have an individual provider number for the carrier that will be paying. Because these services will be billed as professional services and not incident to, the physicians identification number will not work. Even if the physician and the mid-level assistant are from the same practice, they each will need to have different identification numbers to generate the two claims necessary to collect for both providers.

How to Code for Mid-level Assists

Ensuring that the procedure is coded correctly is as important as making sure the mid-level assist meets both legal and payer expectations. As stated above, because the mid-level assist is a professional service, it will be coded on a claim separate from that of the primary surgeon. Both claims should reflect all the same surgical procedure codes.

For example, if a qualified NP assists a physician from your practice in a radical abdominal hysterectomy with bilateral total pelvic lymphadenectomy, lymph biopsy, and removal of tubes and ovaries (58210), you will generate a claim for both the physician and the NP. For the physicians claim simply code 58210. According to Thomas Kent, CMM, former practice manager of a five-provider ob/gyn office and current principal of Kent Medical Management in Dunkirk, MD, if the patient is not a Medicare patient, for the NPs claim you will also list the 58210 but append it with one of the assisting modifiers, -80 (assistant surgeon in non-teaching institutions), -81 (minimum assistant surgeon), or -82 (assistant surgeon in a teaching institution when a qualified resident is not available).

The -80 and -82 modifiers are the appropriate modifiers for any qualified first assist in surgery who is present from the open to the close of the case. According to several consultants, the -81 modifier is rarely used and has uncertain acceptance. Brink says it could possibly be used for a professional assistant in surgery when he or she is only providing help during a portion of the case.

If the patient were a Medicare patient, Kent says coders should append the CPT procedure code with the newly revised specific HCPCS modifier -AS on the mid-levels claim. According to the HCPCS guide, modifier
-AS is for physician assistant, nurse practitioner or clinical nurse specialist services for assistant at surgery.

Note: In the ob/gyn situation where a mid-level assists the obstetrician in a cesarean delivery and the obstetricians claim bills the global cesarean c ode (59510), the surgical assistant should code only the cesarean delivery (59514) along with the appropriate assistant surgeon modifier.

Finally, make sure that the assist was really necessary and that you can back it up with documentation.

What About Reimbursement?

Of course, along with correct reporting, the goal of coding is to obtain maximum reimbursement for these services. Trudy Brody, billing office supervisor for Ob/Gyn Health Center in Medford, OR, says that she has been successful in getting commercial carriers to pay for mid-level surgical assists, but the amount varies. In one recent claim, her practice was reimbursed about $230 for the nurse practitioner who assisted in a cesarean delivery.

Typically, a surgical assist will only pay between 16 and 25 percent of the full charge for the physician performing the procedure. There is some disagreement among consultants on what should be billed. Some say to go ahead and bill the full amount for the procedure on the assists claim and then let the carrier reduce the fee. Keep in mind, however, that the assist is not providing the full service, so many think it is preferable and more accurate to set an assistant fee at a level appropriate for the service rendered. Some consultants suggest a fee that is 25 percent of the full fee. Brody suggests contacting the carrier and seeing what percentage of the total surgical cost they will pay before doing the surgery (and if they have any carrier-specific modifiers). She says, after a few times, youll know what you can expect.